The influence of rurality on women’s decision making and pregnancy choices following an unintended pregnancy: A systematic review

Abstract

Almost half of all pregnancies worldwide and 34% of pregnancies in high-income countries are considered unintended. Several studies from high-income countries report that women from rural areas are more likely to continue their unintended pregnancy and give birth, while urban women are more likely to have an induced abortion. To explore how rurality influences women’s decision making and pregnancy choices following unintended pregnancy by examining the global trends for women who reside in rural areas of high-income countries. This study is a systematic review of qualitative, cross-sectional and mixed-methods studies. A systematic review of peer-reviewed literature, published from January 2000 through to March 2024, retrieved from five databases: CINAHL, Embase, MEDLINE, PsycINFO and PubMed. Restrictions were applied to obtain original research that has been undertaken in high-income countries. The review included studies featuring participants that were either rural women who experience an unintended pregnancy or health care professionals providing direct care to rural women. Nineteen studies met the inclusion criteria and were included in this review. Several factors that influenced rural women’s decision making following an unintended pregnancy were identified: access to abortion services; role of health care professionals; temporal factors; social norms and stigma; social factors and determinants; culture, ethnicity and religion; reproductive coercion and abortion legislation. The Social–Ecological Model highlighted the levels of interaction, the role health care professionals, family members and the wider community in supporting or obstructing rural women’s decision making. Rural women’s pregnancy decision making and reproductive autonomy can be compromised by intimate partners, family members, health professionals and rural culture. Health professionals have a pivotal role in supporting and respecting rural women’s decision making when seeking an abortion and ensuring that rural women have timely access to abortion care. Registration number: PROSPERO CRD 42023409917.

Introduction

Unintended pregnancy refers to a pregnancy that is either unplanned, mistimed and/or unwanted at the time of conception. ¹ Unintended pregnancy has been labelled a ‘global crisis’, ² and despite a decrease in the global trend of unintended pregnancy, it is estimated that almost half of all pregnancies worldwide and 34% of pregnancies in high-income countries (HICs), are still unintended.^2,3 There are a number of factors linked to higher rates of unintended pregnancy, including young age, low income, lower levels of education, rurality, migration background, drug and alcohol use, unmet need for family planning, experience of violence and abuse, lack of reproductive autonomy and reproductive coercion (any behaviour or abuse used to control a person’s reproductive choices).^{4 –9}

Unintended pregnancy increases the risk for adverse maternal and child health outcomes. ¹⁰ If unaware of the pregnancy, an expectant woman may experience later engagement with antenatal care, especially if she fails to recognize pregnancy symptoms. These women may also be less likely to engage in positive pregnancy health behaviours, which include dietary modifications, folic acid supplementation and abstaining from alcohol and smoking.^6,11 Failure to engage in positive pregnancy health behaviours can result in a greater risk of adverse pregnancy and birthing complications such as miscarriage, pre-term birth, stillbirth, a low-birth-weight baby and post-natal depression. ⁶

When an unintended pregnancy occurs, women are faced with the decision of whether to continue the pregnancy and raise the child, have an induced abortion or continue the pregnancy and give the child up for adoption. ¹ It is estimated that 60% of unintended pregnancies worldwide, ² and 43% of unintended pregnancies in HICs end in abortion. ³

Since the 1960s, the average total fertility rate has more than halved in HICs, from 3.29 children/woman in 1960 to 1.63 children/woman in 2019. ¹² Geographical disparities exist within HICs surrounding fertility rates, ¹² unintended pregnancy and outcomes following an unintended pregnancy. ¹³ Generally, women from low-population-density communities such as regional, rural and remote areas have higher rates of fertility and unintended pregnancy.^5,14 Furthermore, studies from Australia, Canada and the United States of America (USA) demonstrate that women from more sparsely populated areas are more likely to continue their unintended pregnancy and give birth, when compared to their urban counterparts who are more likely to have an induced abortion.^10,13,15,16

This systematic review aims to explore the influence of rurality on women’s decision making and pregnancy choices following an unintended pregnancy. Existing research relating to rural–urban disparities associated with unintended pregnancy have focussed on rates of unintended pregnancy and antecedent factors contributing to unintended pregnancy. What is less understood is how these rural–urban disparities shape pregnancy choices and pregnancy outcomes. Most research exploring unintended pregnancy focusses on abortion solely as a pregnancy outcome, whereas this study explores both pregnancy continuation and abortion to more broadly understand how rural women’s decision making is influenced and leads to different pregnancy outcomes.

Methods

Databases and search strategy

Our systematic review was developed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement, ¹⁷ and the study was registered with PROSPERO (registration number CRD 42023409917). The search was conducted in December 2022 and updated on March 16, 2024. Records were retrieved from the following bibliographic databases: CINAHL, Embase, MEDLINE, PsycINFO and PubMed.

Inclusion/exclusion criteria

The review included studies featuring participants who were either rural women who had experienced an unintended pregnancy, health care professionals involved in supporting rural women who experienced unintended pregnancy, and anyone involved in the pregnancy decision making (e.g. males, intimate partners and family). In this review, ‘rural’ is defined as non-urban, low-population-density areas that encompass regional, rural and/or remote locations. The terms ‘rural’, ‘regional’ and ‘remote’ were applied in the search strategy to gain a broader range of studies from a greater number of HICs. The review was limited to original research studies (any study design) and systematic reviews. Literature reviews, narrative reviews, commentary, letter to editors, discussion articles, conference abstracts and grey literature were excluded. Restrictions were applied to obtain studies undertaken in HIC (as classified by the World Bank). Date restrictions were applied to search for records between January 01, 2000 and March 16, 2024, to obtain a more contemporary perspective. Language restrictions were applied to publications in English language.

Screening

Two reviewers applied the eligibility criteria and independently screened titles and abstracts of records using the (Veritas Health Innovation Ltd manufactured) Covidence systematic review evidence synthesis software. ¹⁸ The reviewers were blinded to each other’s decisions, and any disagreements were resolved by a third reviewer, also blinded to the decisions of the two reviewers. Upon completion of title and abstract screening, eligible articles underwent a full-text screen by two reviewers. Any full-text articles that received approval from two reviewers were included for data extraction for the systematic review. Any disagreements were resolved by a third reviewer. In addition, backwards citation chaining was conducted by searching through the reference list of the 11 initially included articles to identify any additional relevant studies. This resulted in eight more articles being assessed as eligible for inclusion in the systematic review.

Data extraction

Data extraction and management for the study were performed, whereby data from the included studies were manually entered onto a Microsoft Excel spreadsheet. The following study characteristics were extracted: basic data (author, publication year, title); study design (methodology, data collection method); study context (country and data collection setting e.g. abortion clinic), setting/location (rural/remote/regional/metropolitan); time period of data collection; participant characteristics (sample, sample size); results (pregnancy outcome, decision-making factors) and ethics approval. The process of data extraction required one reviewer to extract data and a second reviewer to check the extracted data. A third reviewer was utilized to resolve any disagreements between individual judgements.

Critical appraisal

A Risk of Bias (Quality) Assessment was performed using the suite of Joanna Briggs Institute’s (JBI) Critical Appraisal tools to assess the methodological quality of each study according to research design. All studies included in the systematic review were classified as high-quality studies with a JBI score >70% ¹⁹ (refer to Table 1).

Table 1.

Characteristics and quality scores of included studies in the systematic review (according to the first author surname).

Author/year	Country	Study aim	Setting	Study design and data collection	Sample	Sample size	JBI quality score
Cashman, Downing and Russell, 2021	Australia	To determine what aspects of the process from seeking information about abortion services to completion worked well for women and areas for improvement	Cairns Sexual Health Service (regional)	Qualitative study. Semi-structured telephone interviews	Women aged >16 years who accessed MToP services at the CSHS between August 2019 and February 2020	11	9/10 a
Dawson et al., 2017	Australia	To understand the experiences of GPs working in private practice regarding the provision of MToP and referral to other health professionals and services	Primary Healthcare Services in NSW (remote, regional, metropolitan)	Qualitative descriptive-interpretive study. Semi-structured interviews via telephone or face-to-face. One focus group	GPs practicing in NSW	32	10/10 a
de Moel-Mandel, Graham and Takat, 2019	Australia	To identify enablers and barriers to the provision of medication abortion in the primary health care setting of regional and rural areas of Victoria, Australia	Primary Healthcare Services in Victoria (rural, regional)	Cross-sectional study	GPs and Primary Health Care Nurses	69	8/8 b
Doran and Hornibrook, 2016	Australia	To identify factors that women in rural NSW experience in accessing abortion services and suggestions about how rural women could be better supported when seeking access to an abortion service	Rural NSW (rural)	Qualitative study. In-depth interviews	Rural women living in NSW who had had an abortion in the previous 15 years	13	7/10 a
Epstein et al., 2009	USA	To identify rural–urban differences in factors affecting initiation of prenatal care in Oregon	Oregon (rural, metropolitan)	Quantitative observational, cross-sectional study using data collected in the 2003 Oregon PRAMS	Women who gave birth to a live child in Oregon in the 60–180 days before the selection dates of PRAMS survey	1508	8/8 b
Griffiths et al., 2019	Australia	To explore the formation and expression of pregnancy intentions in an Aboriginal population to inform health service improvements	Western Desert region of Western Australia (remote)	Quantitative survey (demographical data) and qualitative semi-structured interviews	Remote-dwelling Aboriginal women	27	10/10 a
Heller et al., 2016	Scotland	To explore women’s perceptions of their pathway to TOP and to examine any impact of delays in obtaining treatment	Scottish Highlands and Western Isles (remote, rural)	Qualitative semi-structured, audio-recorded telephone interviews	Women who had undergone TOP in the Scottish Highlands National Health Service between October 2014 and May 2015	16	9/10 a
Hulme-Chambers et al., 2018	Australia	To understand better rural women’s experiences in obtaining a MToP through a rural Primary Healthcare Service in Victoria, Australia	Rural Victoria (rural)	Qualitative semi-structured interviews	Women who attended a rural sexual health clinic for an MToP between February 2016 and 2017	18	10/10 a
Ireland, Belton and Doran, 2020	Australia	To explore and better understand women’s access to telemedicine abortion in Australian rural areas	Rural areas of Australia (rural)	Qualitative structured telephone interviews	Women living in rural areas who had experienced a telemedicine abortion within the last 6 months	11	10/10 a
Keogh et al., 2019	Australia	To understand rural GPs’ knowledge and practice in relation to unintended pregnancy and referral for abortion, using the Grampians region of Victoria as a case study	Grampians region of Victoria (rural, regional)	Quantitative surveys and qualitative telephone interview	GPs practicing Grampians region of Victoria	23	9/10 a 8/8 b
Kruss and Gridley, 2014	Australia	To examine barriers to accessing three types of family planning service (emergency contraception, termination of pregnancy and options counselling) within the Grampians region of Victoria	Rural Victoria (rural)	Qualitative semi-structured interviews	Health professionals (GP, SW/psychology, nursing) connected to family planning services in Victoria	11	10/10 a
Margo et al., 2016	USA	To highlight supportive and hindering conditions along various pathways to obtaining an abortion in South Carolina	South Carolina (rural, regional, metropolitan)	Qualitative semi-structured interviews	Women obtaining abortions in South Carolina	45	9/10 a
Newton et al., 2016	Australia	To investigate the potential to expand general practice’s role in providing medical abortion in Victoria	Victoria (regional, metropolitan)	Qualitative in-depth semi-structured interviews	Health experts in abortion service provision in Victoria	19	8/10 a
Noonan et al., 2022	Australia	How women living in rural NSW experience managing an unintended pregnancy, including their expectations of local primary care providers, preferences and priorities, and satisfaction with the services they received	Regional cities and towns across Central to Far West NSW (rural, regional)	Qualitative in-depth semi-structured interviews	Rural women who managing an unintended pregnancy	20	9/10 a
O’Donnell et al., 2018	USA	To explore the relationship between residing in a rural county, decision making and ability to obtain abortion services	Rural counties of Central Appalachia (rural)	Qualitative demographic questionnaire followed by semi-structured interviews	English-speaking women aged 16–45 years, residing in rural counties in Central Appalachia, who disclosed experiencing an unwanted pregnancy	31 (16 continued; 15 sought termination)	8/10 a
Otero-Garcia et al., 2013	Spain	To explore the perceptions of midwives who provide these services regarding immigrant women’s access and participation in sexual and reproductive health programmes offered in rural areas	Segovia (rural)	Qualitative (ethnographic) in-depth interviews and field notes	Midwives in primary care serving 13 rural BHZ of Segovia	7	9/10 a
Soon et al., 2015	USA	To elucidate Native Hawaiian perspectives on pregnancy and pregnancy planning	Wai’anae Coast on the island of Oahu in Hawaii (rural)	Qualitative Community-engaged research approach. Semi-structured interviews	Key informants were Community Leaders, who had expertise in Native Hawaiian culture and influences	10	10/10 a
Wellington, Hegarty and Tarzia, 2021	Australia	To address this gap by exploring the barriers to responding to reproductive coercion and abuse in Australian primary care	Australia-wide (remote, rural, metropolitan)	Qualitative semi-structured interviews	Primary Health Care Clinicians across Australia	24	10/10 a
White, Mann and Larkan, 2018	Cook Islands (NZ)	To provide insight into the structural and cultural factors that shape the incidence and outcomes of pregnancy in the Cook Islands from the perspectives of young mothers themselves	Rarotonga and remote outer islands Mauke and Mangaia (remote, regional)	Phenomenology using qualitative semi-structured in-depth interviews	Young females from the Cook Islands who have experienced an unintended pregnancy. Participants are over the age of 18; and having given birth prior to the age of 20	10	10/10 a

BHZ: basic health zones; CSHS: Cairns Sexual Health Service; GPs: general practitioners; JBI: Joanna Briggs Institute; MToP: medical termination of pregnancy; NSW: New South Wales; PRAMS: Pregnancy Risk Assessment Monitoring System; SW: social work; TOP: termination of pregnancy; USA: United States of America.

^aJBI Critical Appraisal tool (qualitative studies).

^bJBI Critical Appraisal tool (cross-sectional studies).

Data analysis

Key findings were extracted from each article and analyzed utilizing reflexive thematic analysis and inductive coding. This process involved familiarization of content within the dataset, coding extracted data based on commonalities whereby data was collated, and the original language used in included studies was preserved, followed by the development of themes that were later reviewed and refined. ²⁰ These themes related to rurality and the factors that influenced the decision making of women who experienced an unintended pregnancy. To highlight the complexity and levels of interaction, the socioecological model ²¹ was adopted in the final step of the analysis to arrange the decision-making themes into the five levels of the model: intrapersonal, interpersonal, institutional, community and public policy levels.

Results

Search results

In total 2008 records were identified with the initial search; 963 of these were duplicates (414 as identified by EndNote, 539 by Covidence and 33 identified manually). Thousand and forty-five studies underwent a title and abstract screen, which resulted in 974 records being excluded. Following a full-text screen of 71 studies, a total of 19 studies met the inclusion criteria and were included in this review (see Figure 1 for PRISMA 2020 statement).

Figure 1.

PRISMA diagram for study selection.

PRISMA: preferred reporting items for systematic reviews and meta-analyses.

Descriptive summary

Studies included were conducted in Australia (n = 12),^{22 –33} USA (n = 4),^{34 –37} New Zealand (n = 1), ³⁸ Scotland (n = 1) ³⁹ and Spain (n = 1). ⁴⁰ Sixteen studies utilized a qualitative research design,^{22,23,25 –28,30 –33,35 –40} two utilized an analytical cross-sectional research design,^24,34 while one study adopted a mixed-methods design. ²⁹ Eleven studies obtained data from women who experienced an unintended pregnancy,^{22,25 –28,32,34 –36,38,39} while eight studies focussed on the perspectives of healthcare providers for example doctors (n = 6)^{23,24,29 –31,33} nurses (n = 4)^24,30,31,33 and midwives (n = 1). ⁴⁰ Most studies (17 out of 19) were published in the last 10 years. Eleven studies had sample sizes of <20 participants. Twelve of the 19 studies focussed exclusively on abortion provision^{22 –25,27 –31,33,35,39}; four studies focussed exclusively on pregnancy continuation^26,34,37,38; while the remaining three studies highlighted factors that contributed to either continue or terminate a pregnancy in rural areas^32,36,40 (see Table 1).

Findings from the systematic review highlight the many factors that influence rural women’s decision making following an unintended pregnancy. These decision-making factors were arranged into the following themes: access to abortion services; the role of health care professionals; temporal factors; social norms and stigma; social factors and determinants; culture, ethnicity and religion; reproductive coercion and abortion legislation (Figure 2 and Table 2).

Figure 2.

Decision-making factors identified using the social–ecological model.

Table 2.

Decision-making factors and social–ecological model level of included studies in the systematic review.

Author/year	Pregnancy outcome	Social–ecological model level factors	Decision-making factors
Cashman, Downing and Russell, 2021	Termination	Intrapersonal Institutional	Access to abortion services Role of health professionals Social norms and stigma
Dawson et al., 2017	Termination	Institutional Community	Access to abortion services Culture, ethnicity and religion Role of health professionals Social norms and stigma Temporal factors
de Moel-Mandel, Graham and Takat, 2019	Termination	Institutional	Access to abortion services Role of health professionals Social norms and stigma
Doran and Hornibrook, 2016	Termination	Intrapersonal Institutional	Access to abortion services Role of health professionals Social factors and determinants Social norms and stigma Temporal factors
Epstein et al., 2009	Continuation	Intrapersonal Institutional	Access to abortion services Role of health professionals Social factors and determinants Temporal factors
Griffiths et al., 2019	Continuation	Interpersonal Community	Culture, ethnicity and religion Reproductive coercion Social factors and determinants
Heller et al., 2016	Termination	Intrapersonal Institutional Community	Access to abortion services Culture, ethnicity and religion Role of health professionals Social factors and determinants Social norms and stigma Temporal factors
Hulme-Chambers et al., 2018	Termination	Intrapersonal Institutional Community	Access to abortion services Role of health professionals Social factors and determinants Temporal factors
Ireland, Belton and Doran, 2020	Termination	Intrapersonal Interpersonal Community	Access to abortion services Culture, ethnicity and religion Reproductive coercion Role of health professionals Social factors and determinants Stigma Temporal factors
Keogh et al., 2019	Termination	Institutional	Access to abortion services Culture, ethnicity and religion Role of health professionals
Kruss and Gridley, 2014	Termination	Intrapersonal Interpersonal Institutional Community	Access to abortion services Culture, ethnicity and religion Role of health professionals Social factors and determinants Stigma Temporal factors
Margo et al., 2016	Termination	Intrapersonal Interpersonal Institutional Public Policy	Abortion legislation Access to abortion services Role of health professionals Social factors and determinants Temporal factors
Newton et al., 2016	Termination	Intrapersonal Institutional Community	Access to abortion services Role of health professionals Stigma Temporal factors
Noonan et al., 2022	Continuation Termination	Intrapersonal Interpersonal Institutional Community	Access to abortion services Role of health professionals Social norms and stigma
O’Donnell et al., 2018	Continuation Termination	Intrapersonal Interpersonal Institutional Community	Access to abortion services Culture, ethnicity and religion Role of health professionals Social norms and stigma
Otero-Garcia et al., 2013	Continuation Termination	Intrapersonal Interpersonal Public Policy	Abortion legislation Access to abortion services Reproductive coercion
Soon et al., 2015	Continuation	Intrapersonal Interpersonal Community	Culture, ethnicity and religion Reproductive coercion Social factors and determinants Social norms and stigma
Wellington, Hegarty and Tarzia, 2021	Termination	Intrapersonal Institutional Public Policy	Abortion legislation Access to abortion services Reproductive coercion Temporal factors
White, Mann and Larkan, 2018	Continuation	Intrapersonal Interpersonal Community Public Policy	Abortion legislation Access to abortion services Culture, ethnicity and religion Social factors and determinants Social norms and stigma Temporal factors

Access to abortion services

Access to abortion services in rural areas emerged as the most prominent theme overall appearing in 15 of the 19 included studies.^{22 –25,27 –36,39} This theme was generally discussed in the context of barriers to abortion access, which included limited access to abortion services and after-care,^{22,23,27 –33,35,39} a lack of tele-abortion services,^{22 –25,27 –33,35,39} service provision costs,^{26,29,31,32,34,36,40} distance to travel^{27,28,31,33,35,39} and inflexibility and delays in obtaining an appointment.^22,30 One article described specifically how lack of access to abortion services directly contributed to some participants’ decisions to continue an unintended pregnancy. ³⁸

Rural women wishing to obtain surgical abortion following an unintended pregnancy experienced limited appointment availability, excessive waiting lists and surgical times and surgical abortion services unavailable close to home. This resulted in some rural women being unable to obtain a surgical abortion. As for medication abortion, limited availability of mifepristone and misoprostol (medicines used in medication abortion regimen) at rural primary health care clinics, hospitals, and pharmacies ³⁹ or refusal of rural health services to provide medication abortion services^24,30,31 made medication abortion inaccessible for many.

Furthermore, the financial cost of obtaining an abortion, accompanying tests, follow-up appointments and related travel were significant barriers identified across studies for rural women who experienced geographical constraints due to the scarcity of services.^{25,27,28,30,31,35,39} One USA study highlighted that a lack of government support to subsidize costs for an abortion meant many rural women were unable to access an abortion, due to being required to self-fund the abortion entirely. ³⁶

Role of health care professionals

The role of health care professionals in rural women’s decision making (which included general practitioners (GPs), nurses, midwives, pharmacists and sonographers) was discussed in 13 studies.^{22 –25,27 –31,34 –36,39} GPs are often seen as a first point of call for health information, however, for some rural women, their experiences indicate that when seeking advice about an abortion, they either received a lack of information or misinformation about pregnancy options, especially relating to medication abortion and the required follow-up visit from their treating health care professional.^25,27,28,32 Three studies highlighted that some GPs lack knowledge about medication abortion and telemedicine abortion services that may be available to rural women, which in turn adversely affect timelines and opportunities for rural women to access an abortion.^24,28,30 Another concern women described was the lack of privacy and anonymity with health services in rural communities, when having to disclose an unintended pregnancy to the family doctor or request an abortion from a health care professional that the women may know.^{29 –31,39} In addition, the lack of medication abortion providers, training opportunities^{22,24,28,29,31} and a lack of sonography (used to confirm pregnancy and gestation age) ³¹ also impacted on access for rural women.

Temporal factors

Timing or temporal factors were discussed across 12 studies,^{22,23,25,27,28,30,31,33 –35,38,39} whereby it impacted rural women’s ability to seek an abortion and led to pregnancy continuation following an unintended pregnancy. Abortion-related temporal factors were linked to either timing associated with a woman’s failure to recognize a pregnancy early enough to access an abortion, delays in obtaining rural GP appointments for abortion access/referrals, time constraints associated with needing blood tests and ultrasounds, time required to administer medication abortion at home and post-abortion recovery period.^{25,34,35,38,39} Three studies discussed temporal factors associated with disclosing an unintended pregnancy to an employer, these included negotiating time off work to travel to abortion services and adjustments to work rosters to attend appointments.^27,35,39 Other temporal factors that rural women have to factor in with obtaining an abortion relate to time away from children and the need to arrange formal/informal childcare due to lengthy travel time.^{27,28,31,35,39}

Social norms and stigma

Abortion stigma appeared in 12 studies, whereby it impeded a woman’s ability to terminate a pregnancy and led to women continuing an unintended pregnancy.^{22 –25,28,30 –32,36 –39} Three articles discussed instances where some rural women experienced internalized moral conflict surrounding abortion and how that influenced their decision making.^30,36,39 For younger rural women who were still living at home with their parents, their parents were influential in decision making following an unintended pregnancy.^36,37 A study conducted in the USA highlighted that parenting norms in Central Appalachia stigmatized abortion and favoured pregnancy continuation, influencing rural women to continue an unintended pregnancy. ³⁶ Some rural women experienced stigma, and discrimination or had their care obstructed by either GPs, pharmacists or sonographers when seeking an abortion.^{22,25,27,28,30,39} Anti-abortion views held by health care professionals either directly or indirectly impeded some rural women’s ability to terminate a pregnancy.^{22,24,25,28,39}

In the Cook Islands, young people on the more remote outer islands experienced greater stigma associated with teenage pregnancy and accessing sexual and reproductive health services (including abortion). ³⁸ Finally, three studies suggested that the absence of an abortion narrative in rural areas, and societal norms whereby the announcement of pregnancy is seen as a celebration of a new life, led to more unintended pregnancies being continued.^28,32,36

Social factors and determinants

Social factors and determinants were explored in the context of how they acted as barriers for rural women seeking an abortion or supported rural women to continue an unintended pregnancy.^{25,26,28,30,34,35,37 –39} Falling pregnant at a younger age, being unmarried, having low educational attainment, low income and socioeconomic disadvantage were described as common characteristics for women who continued an unintended pregnancy in rural areas.^25,34,35,37 Rural women were more likely to continue an unintended pregnancy if career, education and travel were considered a low priority.^30,35,37,38 A study found that rural women in Hawaiian culture were encouraged to continue an unintended pregnancy, as decision making was often determined by ‘ohana’ (family) which viewed childbearing as taking precedence over other maternal/parental life events such as career, education or travel. ³⁷

Social support was shown to increase the likelihood of rural women having greater autonomy in their decision making following an unintended pregnancy, which primarily came from a partner, immediate family and kin,^{26,28,30,35,37,38} but also friends and community in one study. ³⁷ Strong family (including partners) and kin networks supported women to continue an unintended pregnancy in three studies^26,37,38 and abortion in three studies.^28,30,35 One article explained in situations where a woman is in an unstable relationship with the man involved in the pregnancy, they were more likely to seek an abortion. ³⁵ However, another study highlighted due to needing to be driven to access abortion by a nominated support person, not only did it necessitate unwanted pregnancy disclosure, but some rural women were confronted by obstructing behaviour from their support person (partner, family member). ²⁸ Two Australian articles recognized the ability of rural communities to provide social support to women continuing an unintended pregnancy.^26,37

Culture, ethnicity and religion

Culture, ethnicity and religion were discussed in eight studies.^{23,26,28 –30,37 –39} A study conducted in the Cook Islands, where abortion is illegal (unless deemed necessary to save the pregnant woman’s life) and cultural restrictions prevent women from obtaining an abortion, identified the role of culture and ethnicity in shaping women’s decision making. ³⁸ In the Cook Island study, one participant indicated that despite wishing to delay having a child, abortion was never an option due to believing ‘life is life’ leading them to continue an unintended pregnancy. ³⁸ Another study from Hawaii reported that societal pressures, cultural expectations and desirability of children in native Hawaiian culture, led some younger Hawaiian women (or couples) to be ‘discouraged’ from terminating an unintended pregnancy. ³⁷

Two studies found that the religious views held by family members of the pregnant woman were generally supportive of promoting a continuation of pregnancy and had a religious objection to abortion.^28,38 The workplace culture within health organizations or health care professionals’ personal views were also barriers for rural patients and their decision making.^24,30,39,40 Some rural GPs expressed religious and moral objection to abortion, which led to some refusing to refer for abortion or ceasing care to rural patients who had requested an abortion from them.^23,29,30,39

Furthermore, two studies conducted in the USA (Central Appalachia and Hawaii) reported overwhelming support for having children and anti-abortion views contributed to families in these rural communities widely accepting an unplanned pregnancy.^36,37 An Australian study that focussed on Aboriginal and Torres Strait Islander women, generally favoured pregnancy continuation over abortion in Aboriginal and Torres Strait Islander culture as it had the power to bring both family and community together. ²⁶ While another study highlighted the conservative, close-knit and suspicious nature of rural culture as a factor that caused some rural women refraining from terminating an unintended pregnancy. ³⁰

Reproductive coercion

Reproductive coercion was discussed in seven studies whereby rural women experienced reproductive coercion from either a sexual partner, family member, support person or treating doctor.^{26,28,32,33,36 –38} Some women reported experiencing pressure to fall pregnant, cease contraception or male partners threatening to leave women who did not continue their pregnancy.^26,28 In the five studies where an unintended pregnancy was continued, some rural women indicated initially deciding to terminate the pregnancy but experienced reproductive coercion from either an intimate partner, family members, health care professionals or members of their rural community which contributed to a decision to continue an unintended pregnancy.^{26,32,36 –38} A study from Australia ²⁸ illustrated that reproductive coercion was used, whereby 18.2% of rural participants accessing telemedicine abortion services reported being obstructed by their nominated support person.

Another Australian study reported incidences whereby the actions of some rural doctors were seen to obstruct women’s decision making to terminate an unintended pregnancy, thereby forcing some rural women to continue the unwanted pregnancies. ³³ Two studies highlighted incidents whereby women presented and expressed a need to obtain an abortion following an unintended pregnancy but were refused care from their GPs.^22,30 There were suspicions of deliberate delaying of women’s access to abortion by ‘doing harm by withholding [information]’.^22,30

Abortion legislation

Four studies found that in countries where abortion was considered illegal or ambiguity existed surrounding abortion legislation, this caused many rural women to continue an unintended pregnancy.^33,35,38,40 With abortion legal in Spain, some migrant women were reported by rural midwives to select abortion more commonly as an option when experiencing an unintended pregnancy. ⁴⁰ However, state-based abortion laws in Australia, which have varied restrictions around timing, process and eligibility criteria, ⁴¹ made abortion access more difficult and resulted in some rural women continuing an unintended pregnancy. ³³ While in the Cook Islands, where abortion is illegal, the need to travel overseas to obtain an abortion resulted in some rural women having to continue an unwanted pregnancy. ³⁸

Discussion

This systematic review aimed to explore factors that contribute to rural women’s decision making and pregnancy choices following an unintended pregnancy. The findings demonstrate that rural women face several challenges when seeking an abortion following an unintended pregnancy, making it more difficult to access an abortion when compared to women living in urban areas. However, rural women may also experience many enablers to continue an unintended pregnancy, such as strong family, kin, friend and community networks. Findings also demonstrate how social support acts as an enabler for autonomous decision making in relation to both pregnancy continuation^26,37,38 and abortion.^28,30,35 Furthermore, cultural values that accept ‘life is life’, ³⁸ valued childbearing regardless of the circumstance of how the pregnancy occurred^36,37 and recognized a pregnancy as a way to bring families and communities together at the women’s expense. ²⁶

Barriers to accessing abortion services, the role of health professionals, temporal factors and stigma were identified as the most common themes, signifying their profound impact on rural women’s decision making following an unintended pregnancy in HIC. These influencing factors are consistent with other studies that observe rural–urban disparities in abortion access,^13,16,42 and may partly explain why rural women, including rural adolescent women, are more likely than metropolitan women to have an unintended pregnancy resulting in a live birth.^15,43 The American College of Obstetricians and Gynaecologists reports that rural women in the USA have poorer access to women’s health providers, poorer engagement in breast and cervical screening, later initiation of prenatal care and are more likely to have an unintended pregnancy. ⁴⁴ Despite differing health care systems and abortion restrictions, there were similarities between the USA and Australia, with other studies from the USA and Australia demonstrating that the incidence of abortion and repeat abortion decreased the further away women lived from an abortion facility.^45,46 Women in urban areas in the USA are about 20% more likely to have had a prior abortion when compared with women who lived at least 100 miles (estimated 161 km) away. ⁴⁵ To address some of the rural–urban disparities around access to abortion services, an Australian parliamentary inquiry into universal access to reproductive healthcare acknowledged the need for governments to adequately fund local health services in rural areas to provide timely and affordable medication abortion, surgical abortion and tele-abortion services. ⁴⁷ Greater training opportunities for health professionals to prescribe and dispense medication for abortion in rural areas. ⁴⁷

Furthermore, the findings of this review also indicated that in instances where rural women considered education, travel and career aspirations low, they were more likely to continue an unintended pregnancy, which may also partly explain fewer abortions in rural areas where there are generally fewer educational and career opportunities available to women and more conservative/rigid gender norms that expect this from women.^30,35,37,38 Notably, few studies investigated pregnancy continuation as the primary outcome following an unintended pregnancy, this review only features four studies exclusively, which makes it difficult to draw strong conclusions from the evidence provided.^26,34,37,38 This highlights the need for further research with rural women to better identify how they characterize their pregnancy (mistimed or unwanted), how that shapes their decision making and what decision-making factors support them to continue an unintended pregnancy.

While this review explored both pregnancy outcomes (continuation and abortion), it highlighted the complexity of challenges rural women face when accessing an abortion following an unintended pregnancy. When accessing an abortion, rural women need to travel further to access treatment, have limited access to GPs and other health professionals who are directly involved in their care, and experience a greater financial burden overall, when compared to women living in metropolitan areas of HIC. These geographical barriers are not unique to sexual and reproductive healthcare access, as people living in rural and remote areas generally have poorer health and experience geographical barriers when accessing most forms of medical care and treatment.^{48 –50} This may explain some of the disparities between rural and metropolitan women in HIC and suggest that rural women’s decision to continue an unintended pregnancy may not always be their initial decision or plan, but rather the barriers to abortion may be so great that termination does not become an option.

The findings of this review show that partners, immediate and extended family, health care professionals, community members and laws and policies surrounding abortion have an integral role to play in the trajectory of rural women’s decision making following an unintended pregnancy. In terms of social support, assistance either from an individual or social network is valuable during pregnancy, whereby rural women need to feel supported when faced with major life decisions. The role of social support is pivotal in providing emotional, instrumental and informational support to pregnant women and can buffer the impact of potential stresses that occur during times of major life decisions.^51,52 Similarly, rural communities can provide a reliable source of social support to people through offering a deep sense of connection and belonging, which stems from deep-rooted social networks with generations of family members and being more likely to know their neighbours. ⁵³ However, one of the pitfalls of high levels of social connectedness and visibility is the risk that the actions and behaviours (like terminating a pregnancy) of those living in rural communities are more widely known and spoken about, which reinforces why it may be so difficult to discuss personal health matters, like unintended pregnancy and abortion with health care providers in rural communities, out of fear of ostracism and exclusion.^53,54

Limitations

A limitation of this review is that the search only covered studies conducted in five HICs, despite a broad search for HIC literature. Also, most study samples were small and mostly homogenous, with 11 out of 19 studies involving <20 participants. There may be cultural nuances and taboos associated with unintended pregnancy not captured by this review, or inconsistencies with geographical terminology across different countries to denote rurality. All studies were identified as of high quality, and the qualitative studies (n = 16) produced a rich depth of case-oriented analysis, providing richly textured information, subject to the phenomenon of rural women’s experiences of decision making following an unintended pregnancy. ⁵⁵

Conclusion

The findings of this systematic review have provided foundational insight into the complexity of factors that influence rural women’s decision making following an unintended pregnancy in HIC, and the barriers they may face when seeking abortion care. Further research is needed to better understand factors that support rural women to continue an unintended pregnancy, beyond the consequence of being unable to access an abortion, and how to overcome the many barriers to autonomous decision making and access to appropriate care.